eMedicine Specialties > Gastroenterology > Esophagus
Esophageal Hematoma: Treatment & Medication
Updated: Jul 20, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
For spontaneous intramural hematoma, conservative therapy leads to an excellent prognosis. Esophageal hematomas generally resolve within 2-3 weeks with no long-term sequelae.
- Nothing by mouth (NPO) for the first several days. Oral intake should be reintroduced gradually. A soft diet may be started in a stable patient on days 4-6. Parenteral feeding is generally not required, as most patients are able to swallow within a few days.
- Provide intravenous fluids while the patient is NPO and transfusion of blood if needed.
- Acid suppression should also be considered to reduce the risk of esophageal ulceration.
- Antiemetics are indicated as needed.
- Correction of any coagulation abnormalities is indicated.
- Occasionally, extensive esophageal hematomas have been treated by sclerosant injections.
- Because this entity is so rare, a clear indication for this therapeutic approach has not yet been established.
- Complications during endoscopic sclerotherapy include rupture of the intramural hematoma.
Surgical Care
- Surgery is only indicated in patients with massive ongoing hematemesis. This occurred in 19% of patients, as reported in a literature review of 31 patients with esophageal hematoma.
- Via a right thoracotomy, an esophagotomy may expose the bleeding tissue, which is then oversewn.
Consultations
- Cardiologist
- Gastroenterologist
- Thoracic surgeon
Medication
Acid suppression by histamine 2 (H2)-receptor antagonists or proton pump inhibitors is useful to treat or prevent esophageal ulcerations.
Proton pump inhibitors
Inhibit gastric acid secretion by inhibition of the H+/K+/ATP-ase enzyme system in the gastric parietal cells. These agents are used in cases of severe esophagitis and in patients not responding to H2-antagonist therapy.
Omeprazole (Prilosec)
Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ -ATP pump.
Adult
20-40 mg PO qd before breakfast
Pediatric
Not established
May decrease effects of itraconazole and ketoconazole; may increase toxicity of warfarin, digoxin, and phenytoin
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Bioavailability may increase in elderly patients
Lansoprazole (Prevacid)
Inhibits gastric acid secretion. Used for up to 4 wk to treat and relieve symptoms of active duodenal ulcers.
Adult
30 mg PO qd before breakfast
Pediatric
Not established
May decrease effects of ketoconazole and itraconazole; may increase theophylline clearance
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Consider adjusting dose in liver impairment. Prolonged treatment (typically > 3 years) may lead to vitamin B12 malabsorption
Rabeprazole (Aciphex)
Decreases gastric acid secretion by inhibiting the parietal cell H+/K+ -ATP pump.
Adult
20-mg tab PO qd
Pediatric
Not established
May decrease effects of itraconazole and ketoconazole; may increase toxicity of warfarin, digoxin, and phenytoin
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Symptomatic relief with proton pump inhibitors may mask symptoms of gastric malignancy Prolonged treatment (typically > 3 years) may lead to vitamin B12 malabsorption
Esomeprazole magnesium (Nexium)
S-isomer of omeprazole. Inhibits gastric acid secretion by inhibiting H+/K+ -ATP pump at secretory surface of gastric parietal cells.
Adult
20-40 mg PO qd
20-40 mg IV qd IV over 10-30 min or by injection over at least three min
Pediatric
Not established
Amoxicillin or clarithromycin may increase plasma levels of esomeprazole when used concurrently; may reduce absorption of dapsone; may increase levels of diazepam and GI absorption of digoxin; may decrease absorption of iron, ketoconazole, and itraconazole
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Symptomatic relief with proton pump inhibitors may mask symptoms of gastric malignancy Prolonged treatment (typically > 3 years) may lead to vitamin B12 malabsorption
Pantoprazole Sodium (Protonix)
Inhibits gastric acid secretion by inhibiting H+/K+ -ATP pump at secretory surface of gastric parietal cells.
Adult
40 mg PO /IV qd
Pediatric
Not established
May decrease effects of itraconazole and ketoconazole; may increase toxicity of warfarin, digoxin, and phenytoin
Hypersensitivity to pantoprazole, substituted benzamidazoles (ie, esomeprazole, lansoprazole, omeprazole, rabeprazole), or any component of the formulation
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Symptomatic relief with proton pump inhibitors may mask symptoms of gastric malignancy Prolonged treatment (typically > 3 years) may lead to vitamin B12 malabsorption
H2-receptor antagonists
Reversible competitive blockers of histamine at the H2 receptors, particularly those in the gastric parietal cells where they inhibit acid secretion. The H2 antagonists are highly selective, do not affect the H1 receptors, and are not anticholinergic agents.
Ranitidine (Zantac)
Inhibits histamine stimulation of the H2 receptor in gastric parietal cells, which in turn reduces gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Adult
150 mg PO bid; not to exceed 600 mg/d
Alternatively, 50 mg/dose IV/IM q6-8h
Pediatric
Not established
May decrease effects of ketoconazole and itraconazole; may alter serum levels of ferrous sulfate, diazepam, nondepolarizing muscle relaxants, and oxaprozin
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Caution in renal or liver impairment; if changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
Famotidine (Pepcid)
Competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Adult
40 mg/d PO bid
Alternatively, 20 mg IV bid
Pediatric
Not established
May decrease effects of ketoconazole and itraconazole
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
If changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
Nizatidine (Axid)
Competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Adult
300 mg PO hs or 150 mg bid
Pediatric
Not established
None reported
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Caution in renal or liver impairment; if changes in renal function occur during therapy, consider adjusting dose or discontinuing treatment
Cimetidine (Tagamet)
Competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Adult
150 mg PO qid; not to exceed 600 mg/d
Alternatively, 50 mg/dose IV/IM q6-8h; not to exceed 400 mg/d
Pediatric
Not established
Can increase blood levels of theophylline, warfarin, tricyclic antidepressants, triamterene, phenytoin, quinidine, propranolol, metronidazole, procainamide, and lidocaine
Documented hypersensitivity
Pregnancy
B - Usually safe but benefits must outweigh the risks.
Precautions
Elderly patients may experience confusional states; may cause impotence and gynecomastia in young males; may increase levels of many drugs; adjust dose or discontinue treatment if changes in renal function occur
More on Esophageal Hematoma |
| Overview: Esophageal Hematoma |
| Differential Diagnoses & Workup: Esophageal Hematoma |
 Treatment & Medication: Esophageal Hematoma |
| Follow-up: Esophageal Hematoma |
| References |
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References
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Further Reading
Keywords
esophageal apoplexy, esophageal mucosal tears, Mallory-Weiss syndrome, transmural perforation, Boerhaave syndrome, intramural hematoma of the esophagus, esophageal perforation, mediastinitis, abscess formation, vomiting, dysphagia, odynophagia, hematemesis, severe acute chest pain
